Purpose: To describe the signs, symptoms, and treatment of blood and blood component transfusion reactions.

Policy: Compared with many medical and surgical interventions, blood and blood component transfusions are relatively safe. However, morbidity and mortality do still occur, and the root cause of many preventable reactions is human error. Mortality rates from acute transfusion reactions, for example, are approximately 0.6 per million. In the United States, TACO is the most likely transfusion reaction to be fatal. From 2013-2017, there were 185 deaths reported from transfusion: TACO (59); TRALI (56); AHTR (32); Non-ABO incompatibility (20); ABO incompatibility (12); Sepsis (23); Anaphylaxis (12); and Hypotensive reactions (3).

Transfusion-transmitted infection is now a rare event but there is no room for complacency as the emergence of new infectious agents requires constant vigilance.

Hemovigiliance is the “systematic surveillance of adverse reactions and adverse events related to transfusion” with the aim of improving transfusion safety. Transfusion reactions and adverse events should be investigated by the transfusion medical director, clinicians, transfusion nurse, and the blood bank involved in the transfusion process. Adverse reactions and events should be reported as required by law to the FDA.

Adverse effects of transfusion are commonly classified as infectious or non-infectious; acute or delayed; caused by errors or pathological reactions; and by their severity (mild, moderate, or severe).

Types of Transfusion Reactions:

  1. Noninfectious
    1. Acute Reactions
    2. Delayed Reactions
  2. Infectious

PROCEDURE

  1. Noninfectious Acute Adverse Transfusion Reactions
    1. Acute hemolytic transfusion reaction
      1. Definition: Antibody-mediated destruction of red blood cells in a patient and can be attributed to incompatible red blood cells or plasma.
      2. Pathology: May be mild or severe. Most commonly caused by the transfusion of ABO-incompatible red cells that react with the patient’s anti-A or anti-B antibodies. Most commonly caused by human error when taking or labeling the pre-transfusion blood samples, collecting components from the blood bank, and/or failing to perform a correct identity check of blood pack and patient at the bedside.
  • Signs/Symptoms:
    1. Acute Kidney injury
    2. Anemia
    3. Chills
    4. Dyspnea
    5. Feeling of ‘impending doom’ in the first few minutes of transfusion
    6. Fever
    7. Flushing
    8. Hematuria
    9. Hemolysis
    10. Hypotension
    11. Pain, especially abdominal/flank pain
    12. Rigors
    13. Shock
    14. Tachycardia
  1. Transfusion Nurse Interventions
    1. Stop infusion & save tubing and remaining blood for investigation.
    2. Call medical provider (physician or advanced practice provider) covering for patient’s medical care, notify of concerns, and obtain any additional orders.
      1. Notify Medical Director of Versafusion immediately if unable to contact the covering medical provider.
    3. Assess airway, breathing, circulation.
    4. Begin resuscitation measures, if necessary.
    5. Maintain venous access with 0.9% sodium chloride.
    6. Monitor vital signs, urinary output, oxygen saturation.
    7. Check the compatibility label on the blood pack against the patient’s ID band (and see confirmation of identity from the patient, if possible).
    8. Inform the transfusion laboratory/blood bank urgently. If the wrong blood has been transfused, another patient may be at risk. Return the sealed transfusion pack and infusion tubing to the blood bank for investigation.
    9. Obtain transfusion reaction panel and other labs as ordered.
      1. Deliver to lab/blood bank for analysis.
    10. Activate Acute Transfusion Reaction Protocol.
  2. Medical Interventions
    1. Infuse bolus normal saline 100-200 ml/hour.
      1. Avoid Ringer’s lactate and solutions containing dextrose.
    2. If hypotension develops, transfer patient to hospital.
  3. Allergic/Anaphylactic or anaphylactoid transfusion reaction
    1. Definition: Reaction occurring from the release of histamine during a blood transfusion.
    2. Pathology: May occur with all blood components but are most common in platelets and fresh frozen plasma. Mediated by immunoglobulin E antibodies binding to allergens, ultimately resulting in the release of histamine. Typically occur during the transfusion process or within 4 hours after transfusion.
  • Signs/Symptoms:
    1. Dyspnea
    2. Flushing
    3. Pruritis
    4. Severe hypotension
    5. Shock
    6. Stridor from laryngeal edema
    7. Swelling of face, limbs, or mucous membranes (angioedema)
    8. Urticaria (hives)
    9. Wheezing
  1. Transfusion Nursing Interventions:
    1. Stop infusion and maintain save tubing and remaining blood for investigation.
    2. Call medical provider (physician or advanced practice provider) covering for patient’s medical care, notify of concerns, and obtain any additional orders.
      1. Notify Medical Director of Versafusion immediately if unable to contact the covering medical provider.
    3. Assess airway, breathing, circulation.
    4. Begin resuscitation measures, if necessary.
    5. Urgent medical care should be called immediately (911).
    6. Monitor vitals signs, urinary output, oxygen saturation.
    7. Obtain transfusion reaction panel and other labs as ordered.
      1. Deliver to lab/blood bank for analysis.
    8. Activate Acute Transfusion Reaction Protocol.
  2. Medical Interventions:
    1. After initial resuscitation, parenteral steroids or antihistamines may be given but these should not be the first-line therapy.
  3. Transfusion of blood component contaminated by bacteria
    1. Definition: Infection via the blood transfusion of a bacteria.
    2. Pathology: Most often occurring with platelet components than red blood cells, but occurs most often when blood component is contaminated by bacteria from donor skin during donation process. Red blood cells are stored at temperatures lower than platelets that do not allow for the growth of bacteria as readily as the temperature at which platelets are stored.
  • Signs/Symptoms:
    1. Rigors
    2. Fever (>2°C above baseline)
    3. Hypotension
    4. Rapidly developing shock
    5. Rapidly impaired consciousness
  1. Transfusion Nursing Interventions:
    1. Stop the transfusion and save tubing and remaining blood for investigation.
    2. Call medical provider (physician or advanced practice provider) covering for patient’s medical care, notify of concerns, and obtain any additional orders.
      1. Notify Medical Director of Versafusion immediately if unable to contact the covering medical provider.
    3. Assess airway, breathing, circulation.
    4. Begin resuscitation measures, if necessary.
    5. Inspect the sealed blood component pack for abnormal discoloration, aggregates or offensive smell.
    6. Inform the transfusion laboratory/blood bank urgently so that any associated components from the implicated donation can be urgently identified and withdrawn from the blood bank.
    7. Implicated components must be sealed to avoid leakage or contamination. Return the sealed transfusion pack and infusion tubing to the blood bank for investigation.
    8. Monitor vital signs, urine output, oxygen saturation.
    9. Obtain transfusion reaction panel and other labs as ordered.
      1. Deliver to lab/blood bank for analysis.
    10. Activate Acute Transfusion Reaction Protocol.
  2. Medical Interventions:
    1. Begin empiric parenteral antibiotic therapy, typically vancomycin plus a broad spectrum beta-lactation OR an aminoglycoside.
  3. Febrile nonhemolytic transfusion reaction
    1. Definition: Fever, sometimes accompanied by chills, rigors, muscle pain, and nausea, which occurs up to 4 hours post-transfusion.
    2. Pathology: More common in multi-transfused patients receiving red blood cells. Caused by recipient antibodies binding to white blood cells in the blood component, or proinflammatory cytokines produced within the component. Diagnosis of exclusion, made only after other more serious reactions and any contributions from an underlying condition are ruled out.
  • Signs/Symptoms:
    1. Chills
    2. Hypertension
    3. Muscle pain
    4. Nausea
    5. Pyrexia
      1. Mild: Temperature is >38°C, but <2°C rise from baseline.
      2. Moderate: Temperature is >39°C or >2°C above baseline or rigors and/or myalgia.
    6. Rigors
    7. Tachycardia
    8. Tachypnea
  1. Transfusion Nursing Interventions:
    1. Activate Acute Transfusion Reaction Protocol.
      1. If mild reaction, slow (or temporarily stop) the rate of the blood transfusion.
        1. Administer anti-pyretic, if ordered.
      2. If moderate, stop the transfusion and save the tubing and remaining blood for further investigation. Consider restarting transfusion with a new unit of blood once symptoms improve.
    2. If symptoms worsen, or do not resolve quickly, consider the possibility of a hemolytic or bacterial reaction.
    3. Call medical provider (physician or advanced practice provider) covering for patient’s medical care, notify of concerns, and obtain any additional orders.
      1. Notify Medical Director of Versafusion immediately if unable to contact the covering medical provider.
    4. Assess airway, breathing, circulation.
    5. Inform the transfusion laboratory/blood bank. Return the sealed transfusion pack and infusion tubing to the blood bank for investigation.
    6. Monitor vital signs, urine output, oxygen saturation.
    7. Obtain blood sample for transfusion reaction panel and deliver to lab/blood bank for analysis.
  2. Medical Interventions:
    1. Administer antipyretic, if desired by patient.
    2. Evaluate for other causes of fever.
    3. Transfer patient to hospital, if indicated.
  3. Transfusion-associated circulatory overload (TACO)
    1. Definition: Acute or worsening pulmonary edema within 6 hours of transfusion.
    2. Pathology: May now be the most common cause of transfusion-related death in developed countries. Elderly patients are at a particular risk and those with predisposing conditions such as heart failure, renal impairment, low albumin concentration, and fluid overload. Small patients like the frail elderly are at increased risk of receiving an inappropriately high volume and rapid blood transfusions. Most commonly occurs in red cell transfusions but can occur in high volume fresh frozen plasma transfusions.
  • Signs/Symptoms:
    1. Acute respiratory distress
    2. Bilateral pulmonary interstitial infiltrates
    3. Chills
    4. Dyspnea
    5. Evidence of positive fluid balance
    6. Fever
    7. Hypertension
    8. Hypoxemia
    9. Jugular venous distention
    10. Peripheral edema
    11. Pleural effusions
    12. Tachycardia
    13. Tachypnea
  1. Transfusion Nursing Interventions:
    1. Evaluate patient prior to transfusion for signs/symptoms of volume overload. If below criteria are met, contact medical provider and ask if furosemide 20 mg IV x 1 dose should be given prior to transfusion and use lower transfusion rate starting at 100 cc/hr up to 125 cc/hr.
      1. Shortness of breath with associated pulmonary rales
      2. 2+ or greater peripheral edema
      3. Jugular venous distension seen at the angle of the jaw
      4. Clinical history of the following diagnoses:
        1. Congestive heart failure
        2. Acute kidney injury with creatinine of > 2.5
  • Chronic kidney disease stages IV through VI
  1. Hemoglobin <6 g/dL
  2. Severe Chronic Obstructive Pulmonary Disease
  3. Cirrhosis of the liver
  • Albumin < 2.0
  • Prior history of TACO
  1. If symptoms develop during transfusion and the following symptoms are present:
  • New or worsening shortness of breath with definite change from pre-transfusion state;
  • New hypoxia with O2 sat <88% and a change of >4% from pre-transfusion baseline;
  • Respiratory distress with tachypnea and accessory muscle use;
  • New 2+ edema or JVD seen at the angle of the jaw, not present during pre-transfusion state;
  • New tachycardia and hypertension with any degree of shortness of breath.
    1. Stop the transfusion and save tubing and remaining blood for further investigation.
    2. Activate TACO emergency protocol
      1. Give furosemide 40 mg IV x 1
      2. Apply oxygen via nasal cannula at 2L/min and titrate to maintain oxygen saturation to >88%.
  • Call medical provider (physician or advanced practice provider) covering for patient’s medical care, notify of concerns, and obtain any additional orders.
    1. Notify Medical Director of Versafusion immediately if unable to contact the covering medical provider.
  1. Assess airway, breathing, circulation.
  2. Begin resuscitation measures, if necessary.
  3. Monitor vital signs, urine output, oxygen saturation.
  1. Inform the transfusion laboratory/blood bank urgently. Return the sealed transfusion pack and infusion tubing to the blood bank for investigation.
  2. Obtain blood sample for transfusion reaction panel and other labs as ordered and deliver to lab/blood bank for analysis.
  3. Activate Acute Transfusion Reaction Protocol, if symptoms do not improve.
  1. If symptoms develop post transfusion:
    1. Facility nurse should contact medical provider on call.
    2. Call medical provider (physician or advanced practice provider) covering for patient’s medical care, notify of concerns, and obtain any additional orders.
      1. Notify Medical Director of Versafusion immediately if unable to contact the covering medical provider.
    3. Assess airway, breathing, circulation.
    4. Begin resuscitation measures, if necessary.
    5. Apply oxygen via nasal cannula at 2L/min and titrate to maintain oxygen saturation to >88%.
    6. Monitor vital signs, urine output, oxygen saturation.
    7. Obtain blood sample for transfusion reaction panel and other labs as ordered and deliver to lab/blood bank for analysis.
  2. Other Interventions:
    1. Follow up after 30 minutes on patient status.
    2. Notify physician for order to administer additional IV loop diuretic therapy as clinically appropriate.
  3. Transfusion-related acute lung injury (TRALI)
    1. Definition: no hydrostatic, noncardiogenic pulmonary edema occurring typically within six hours of transfusion.
    2. Pathology: Most cases present with 2 hours of transfusion (maximum 6 hours); caused by antibodies in the donor blood reacting with the patient’s neutrophils, monocytes, or pulmonary endothelium. Inflammatory cells are sequestered in the lungs, causing leakage of plasma in the alveolar spaces (non-cardiogenic pulmonary edema). Most commonly occurs after transfusion of plasma-rich blood components such as fresh frozen plasma or platelets. Implicated donors are usually females sensitized during previous pregnancy.
  • Signs/Symptoms:
    1. Bilateral pulmonary interstitial infiltrates
    2. Chills
    3. Cough with frothy pink sputum
    4. Dyspnea
    5. Fever
    6. Hypotension (due to loss of plasma volume)
    7. Hypoxemia
    8. Reduced oxygen saturation
    9. Rigors
    10. Tachycardia
    11. Tachypnea
    12. Transient peripheral blood neutropenia or monocytopenia on CBC
    13. Bilateral nodular shadowing in lung fields with normal heart size on chest x-ray
  1. Transfusion Nursing Interventions:
    1. Stop the transfusion and save the tubing and remaining blood for investigation.
    2. Call medical provider (physician or advanced practice provider) covering for patient’s medical care, notify of concerns, and obtain any additional orders.
      1. Notify Medical Director of Versafusion immediately if unable to contact the covering medical provider.
    3. Assess airway, breathing, circulation.
    4. Begin resuscitation measures, if necessary.
    5. Apply oxygen via nasal cannula at 2 L/min and titrate to maintain oxygen saturation >88%.
    6. Inform the transfusion laboratory/blood bank urgently. Return the sealed transfusion pack and infusion tubing to the blood bank for investigation.
    7. Monitor vital signs, urine output, oxygen saturation.
    8. Obtain blood sample for transfusion reaction panel and other labs as ordered and deliver to lab/blood bank for analysis.
    9. Activate Acute Transfusion Reaction Protocol.
  2. Medical Interventions:
    1. Retrospective confirmation of TRALI requires the demonstration of antibodies in the donor’s plasma that react with antigens on the patient’s white blood cells.
    2. Obtain chest x-ray.
    3. If hypoxia persists on 4 L/min oxygen or greater, or patient has difficulty breathing, transfer to acute care facility.
  3. Mild allergic reaction
    1. Definition: Itching and/or skin rash with no change in vital signs.
    2. Pathology: Most commonly occurs in patients receiving plasma-rich components such as fresh frozen plasma or platelets. Symptoms often improve if transfusion is slowed and antihistamine is administered.
  • Signs/Symptoms:
    1. Pruritis
    2. Skin rash/hives
  1. Transfusion Nursing Interventions
    1. Slow the rate of the blood transfusion, or temporarily stop infusion.
    2. Call medical provider (physician or advanced practice provider) covering for patient’s medical care, notify of concerns, and obtain any additional orders.
      1. Notify Medical Director of Versafusion immediately if unable to contact the covering medical provider.Administer antihistamine, if ordered.
    3. Activate Acute Blood Transfusion Reaction Protocol.
      1. If symptoms improve, continue transfusion.
      2. If symptoms do not improve:
        1. Assess airway, breathing, circulation.
        2. Assess for other signs/symptoms of anaphylaxis.
  • Begin resuscitation measures, if necessary.
  1. Obtain blood sample for transfusion reaction panel and other labs as ordered and deliver to lab/blood bank for analysis.
  2. Monitor vital signs, urine output, oxygen saturation.
  1. Medical Interventions:
    1. Order diphenhydramine 50 mg IV.
    2. If symptoms improve, consider restarting transfusion.
    3. If symptoms do not improve, consider transferring patient to acute care facility.
  2. Hypotensive reactions
    1. Definition: Isolated fall in systolic blood pressure of 30 mmHg or more (to <80 mmHg) during, or within one hour of, transfusion with no evidence of an allergic reaction or hemorrhage.
    2. Pathology: Unknown cause, but more common in patients taking ACE inhibitors.
  • Signs/Symptoms:
    1. Reduction of systolic blood pressure of 30 mmHg
  1. Transfusion Nursing Interventions:
    1. Stop the transfusion and save the tubing and remaining blood for investigation.
    2. Call medical provider (physician or advanced practice provider) covering for patient’s medical care, notify of concerns, and obtain any additional orders.
      1. Notify Medical Director of Versafusion immediately if unable to contact the covering medical provider.
    3. Assess airway, breathing, circulation.
    4. Begin resuscitation measures, if necessary.
    5. Place patient in recovery position, with head of bed flat and legs elevated.
    6. Inform the transfusion laboratory/blood bank urgently. Return the sealed transfusion pack and infusion tubing to the blood bank for investigation.
    7. Monitor vital signs, urine output, oxygen saturation.
    8. Obtain blood sample for transfusion reaction panel and other labs as ordered and deliver to lab/blood bank for analysis.
    9. Activate Acute Transfusion Reaction Protocol.
  2. Medical Interventions:
    1. Give normal saline 500 mL bolus IV and repeat until SBP > 90 mmHg or until 2000 mL given.
    2. Transfer patient to acute care facility if hypotension was severe (systolic blood pressure < 70 mmHg) or did not resolve after initial fluid bolus.
  3. Noninfectious Delayed Adverse Transfusion Reactions
    1. Delayed hemolytic transfusion reaction (DHTR)
      1. Definition: Antibody-mediated destruction of red blood cells in a patient and can be attributed to incompatible red blood cells or plasma more than 24 hours after transfusion.
      2. Pathology: Occurs more than 24 hours posttransfusion in a patient who has previously been “alloimmunized” to a red cell antigen by blood transfusion or pregnancy. The antibody may have fallen to a level that is undetectable by the pretransfusion antibody screen and the patient is then re-exposed to red calls of the immunizing group. Antibodies to the Kidd (Jk) blood group system are the most common cause of DHTRs, followed by antibodies to Rh antigens. Transfusion of antigen-positive red cells causes a boost in the patient’s antibody levels (secondary immune response) leading to hemolysis of the transfused cells. Hemolysis becomes clinically apparent up to 14 days after the transfusion. In sickle cell patients, can be misdiagnosed as a sickle cell crisis.
  • Signs/Symptoms:
    1. Acute renal failure
    2. Anemia
    3. Chills
    4. Dark urine
    5. Dyspnea
    6. Fever
    7. Jaundice
    8. Pain
    9. Rigors
  1. Nursing Interventions:
    1. Call medical provider (physician or advanced practice provider) covering for patient’s medical care, notify of concerns, and obtain any additional orders.
    2. Obtain lab work as ordered.
    3. Administer medications as ordered.
    4. Notify transfusion nurse.
  2. Transfusion Nurse Interventions:
    1. Notify Medical Director of Versafusion.
    2. Notify blood bank of suspected reaction and follow their guidelines for further investigation.
  3. Medical Interventions:
    1. Blood work: CBC and reticulocytes, examination of blood film, plasma bilirubin, renal function tests, LDH. Repeat blood group and antibody screen; DAT, and elation of antibodies from the patient’s red cells for identification.
    2. Treatment supportive; sometimes another transfusion is warranted.
  4. Posttransfusion purpura (PTP)
    1. Definition: development of a very low platelet count and bleeding 5-12 days after transfusion of red blood cells.
    2. Pathology: Most common patient is a parous female who is negative for a common platelet antigen, most commonly HPA-1a, and may have been initially sensitized by carrying a HPA-1a positive fetus in pregnancy. PTP is caused by restimulation of platelet-specific alloantibodies in the patient that also damage their own (antigen-negative) platelets by an “innocent bystander” reaction. Very rare reaction.
  • Signs/Symptoms:
    1. Bleeding
    2. Petechiae
    3. Purpura
    4. Rapid-onset thrombocytopenia
  1. Nursing Interventions:
    1. Call medical provider (physician or advanced practice provider) covering for patient’s medical care, notify of concerns, and obtain any additional orders.
    2. Notify transfusion nurse.
    3. Obtain lab work as ordered.
    4. Administer medications as ordered.
    5. Place patient on bleeding precautions.
  2. Transfusion Nurse Interventions:
    1. Notify Medical Director of Versafusion.
    2. Notify blood bank of suspected reaction and follow their guidelines for further investigation.
  3. Medical Interventions:
    1. Transfer patient to an acute-care hospital for administration of IVIG.
  4. Transfusion-associated-graft-versus-host disease (TA-GvHD)
    1. Definition: Rare, almost always fatal complication resulting from viable donor lymphocytes surviving, engrafting, and targeting recipient tissues.
    2. Pathology: occurs when viable lymphocytes in a blood donation engraft in the patient and mount an immune response against the recipient’s cells of a different HLA type. Patients at risk usually have impaired cell-mediated immunity and are unable to reject the foreign cells, such as patients with inherited immunodeficiency disorders affecting T-cell function, medical procedures causing very severe immunosuppression such as allogenic stem cell transplantation or treatment with specific chemotherapy drugs. TA-GvHD has been reported in non-immunosuppressed patients receiving a blood transfusion from an HLA-matched donor or close relative with HLA types in common. Symptoms occur 7-14 days (maximum 30 days) after transfusion.
  • Signs/Symptoms:
    1. Abdominal pain
    2. Diarrhea
    3. Erythema
    4. Fever
    5. Hepatic dysfunction
    6. Maculopapular rash
    7. Nausea
    8. Pancytopenia
    9. Vomiting
  1. Nursing Interventions:
    1. Call medical provider (physician or advanced practice provider) covering for patient’s medical care, notify of concerns, and obtain any additional orders.
    2. Obtain labs as ordered.
    3. Administer medications as ordered.
    4. Notify transfusion nurse.
  2. Transfusion Nurse Interventions:
    1. Notify Medical Director of Versafusion.
    2. Notify blood bank of suspected reaction and follow their guidelines for further investigation.
  3. Medical Interventions:
    1. Transfer patient to acute care facility.
  • Infectious Hazards of Transfusion
    1. Viral infections
      1. Definition: Infection via the blood transfusion of bloodborne virus.
      2. Pathology: Viruses which can be transmitted via blood transfusion include: hepatitis A, B, C, & E; HIV 1 & 2; cytomegalovirus (CMV); human T-cell lymphotropic virus I and II; human parvovirus B19 (HPV B19); and West Nile virus. With modern donor selection and testing, hepatitis B, hepatitis C, and HIV transmission are very rare.
  • Signs/Symptoms:
    1. Signs and symptoms consistent with virus transmitted.
  1. Nursing Interventions:
    1. Call medical provider (physician or advanced practice provider) covering for patient’s medical care, notify of concerns, and obtain any additional orders.
    2. Notify transfusion nurse, if a delayed finding.
    3. Obtain lab work as ordered.
    4. Administer medication as ordered.
  2. Transfusion Nurse Interventions:
    1. If acute finding, call medical provider (physician or advanced practice provider) covering for patient’s medical care, notify of concerns, and obtain any additional orders.
    2. If acute or delayed, notify Medical Director of Versafusion.
    3. Notify blood bank of possible viral infection via blood transfusion.
      1. Follow directions given by blood bank services for further investigation.
    4. Medical Interventions:
      1. Refer patient to infectious disease specialist, or gastroenterologist for hepatitis, for additional monitoring and treatment of viral infection.
    5. Bacterial infections
      1. Definition: Infection via the blood transfusion of a bacteria.
      2. Pathology: Most often derived from the donor arm at the time of collection, which can proliferate on storage and harm the recipient. Bacteria from the normal skin flora rarely produce severe reactions although febrile reactions may occur. More pathogenic gram positive bacteria, such as Staphylococcus aureus, and gram negatives, such as E. Coli, Klebsiella spp. & Pseudomonas spp., may produce life-threatening reactions. Most often occur from platelets because of their high temperature storage, but can occur from red blood cells. Risk of bacterial infections increases with storage time after donation and is the main reason for the short shelf life of platelet components.
  • Signs/Symptoms:
    1. Rigors
    2. Fever (>2°C above baseline)
    3. Hypotension
    4. Rapidly developing shock
    5. Rapidly impaired consciousness
  1. Transfusion Nursing Interventions:
    1. Stop the transfusion and save tubing and remaining blood for investigation.
    2. Call medical provider (physician or advanced practice provider) covering for patient’s medical care, notify of concerns, and obtain any additional orders.
      1. Notify Medical Director of Versafusion immediately if unable to reach medical provider.
    3. Assess airway, breathing, circulation.
    4. Begin resuscitation measures, if necessary.
    5. Inspect the sealed blood component pack for abnormal discoloration, aggregates or offensive smell.
    6. Inform the transfusion laboratory/blood bank urgently so that any associated components from the implicated donation can be urgently identified and withdrawn from the blood bank.
    7. Implicated components must be sealed to avoid leakage or contamination. Return the sealed transfusion pack and infusion tubing to the blood bank for investigation.
    8. Monitor vital signs, urine output, oxygen saturation.
    9. Obtain blood sample from patient for investigation: CBC, renal and liver function tests, urine for hemoglobin, blood cultures, and other labs as ordered.
  2. Medical Interventions:
    1. Begin empiric parenteral antibiotic therapy, typically vancomycin plus a broad spectrum beta-lactam OR an aminoglycoside.
  3. Protozoal infections
    1. Definition: Infection of Protozoa from transfused blood.
    2. Pathology: Malaria and Chagas disease are the two protozoal agents that may be transmitted via blood transfusion. Very rare in the U.S.
  • Signs/Symptoms:
    1. Signs and symptoms consistent with specific protozoa.
  1. Nursing Interventions:
    1. Call medical provider (physician or advanced practice provider) covering for patient’s medical care, notify of concerns, and obtain any additional orders.
    2. Obtain lab work as ordered.
    3. Administer medication as ordered.
    4. Notify transfusion nurse, if delayed reaction.
  2. Transfusion Nurse Interventions:
    1. If acute reaction, call medical provider (physician or advanced practice provider) covering for patient’s medical care, notify of concerns, and obtain any additional orders.
    2. Notify Medical Director of Versafusion.
    3. Notify blood bank of possible protozoal infection via blood transfusion.
      1. Follow directions given by blood bank services for further investigation.
    4. Medical Interventions:
      1. Begin empiric oral or parenteral antibiotic therapy
    5. Creutzfedlt-Jakob Disease (CJD) and Variant Creutzfeldt-Jakob Disease (vCJD)
      1. Definition: CJD AKA spongiform encephalopathy is a rare genetic disease that may be familial or a spontaneous mutation. Low levels are found in the blood with theoretical ability to transmit through transfusion. vCJD is a prion disease that may be contracted through consumption of meat contaminated with infected brain or spinal tissue such as “Mad Cow Disease” in cattle or “Scrapie” in sheep.  May also contract through eating brains of monkeys which is considered a delicacy in Viet Nam and parts of China.
      2. Pathology: Caused by the same agent (abnormal variant of prion protein) as bovine spongiform encephalopathy (BSE) in cattle and caused by eating beef from affected animals.
  • Signs/Symptoms:
    1. Blurred vision or blindness
    2. Difficulty speaking
    3. Difficulty swallowing
    4. Impaired thinking
    5. Insomnia
    6. Loss of coordination
    7. Memory loss
    8. Personality changes
    9. Sudden, jerky movements
  1. Nursing Interventions:
    1. Notify physician/nurse practitioner of suspected reaction.
    2. Obtain lab work as ordered.
    3. Administer medication as ordered.
    4. Notify transfusion nurse.
  2. Transfusion Nurse Interventions:
    1. Call medical provider (physician or advanced practice provider) covering for patient’s medical care, notify of concerns, and obtain any additional orders.
    2. Notify Medical Director of Versafusion.
    3. Notify blood bank of possible infection via blood transfusion.
      1. Follow directions given by blood bank services for further investigation.
    4. Medical Interventions:
      1. Referral to neurologist for monitoring and consideration of clinical trial.
      2. Mostly supportive care.
    5. Further Patient Investigations to Consider Based on Symptoms
      1. Fever (>2°C or >39°C) and/or chills, rigors, myalgia, nausea or vomiting, and/or loin pain
        1. Samples for repeat compatibility testing
        2. Direct antiglobulin test (DAT)
  • Lactate dehydrogenase (LDH)
  1. Haptoglobins
  2. Blood cultures
  3. Coagulation screen
  1. Angioedema (mucosal swelling)
    1. IgA level
      1. If <0.07 g/L, perform confirmatory test with sensitive method and check for IgA antibodies
    2. Dyspnea, Bronchospasm, Anaphylaxis symptoms
      1. Oxygen saturation
      2. Blood gases
  • Chest x-ray
  1. IgA level
  2. Serial mast cell tryptase (immediate, 3, and 24 hours), if severe reaction
  1. Hypotension: isolated fall in systolic blood pressure of >30 mmHg resulting in a level of <80 mmHg
    1. IgA level
    2. Serial mast cell tryptase, if combined with severe allergic reaction
  2. Follow-up/Debriefing after transfusion reaction occurrence
    1. Transfusion Nurse and Medical Director will meet within 48 hours after reporting a blood or blood component transfusion reaction.
      1. Root cause analysis
      2. Prevention of future reactions, if possible
    2. Transfusion Nurse and Medical Director will meet with Blood bank services once their investigation is complete to discuss findings.
    3. Reactions will be reported as required by law to the FDA and state agencies.
      1. A joint report with the blood bank will be submitted.